[Video laparoscopic cholecystectomy in acute cholecystitis: when,how and why?]. / La videolaparocolecistectomia nella colecistite acuta. Quando, come e perché?

Acute cholecystitis has been previously considered as contraindication for laparoscopic cholecystectomy (LC), but recently, several studies have demonstrated that the laparoscopic approach can also be effective in such cases, although iatrogenic lesions of the biliary tree have been increasingly reported. Aim of this study was to verify the effectiveness of LC in patients presenting with acute cholecystitis on the basis of preoperative and intraoperative findings, postoperative mortality and morbidity, in order to assess those conditions which still can be considered as contraindications for LC. From September 1992 to January 1995, 133 patients have been consecutively admitted and operated for LC. 46 cases (36.5%) had histologically proven acute cholecystitis. Moreover we have compared preoperative date (clinical history, laboratory findings, Rx and ultrasound evaluation) with intraoperative findings to assess a correlation with intraoperative difficult conditions evaluated according to De Manzini score. Our results demonstrate that clinical data significantly correlate with intraoperative difficult situations. Hepatobiliary ultrasound also has shown good correlation between the thickness of gallbladder wall and difficult operations (73.9 sensibility-70.1 specificity). Therefore, in patients with clinically severe acute cholecystitis, and thickened gallbladder demonstrated by ultrasound it is very likely that the surgeon will experience difficult in intraoperative situations. In these conditions laparoscopy may be considered mainly as a diagnostic procedure in order to evaluate the entity of inflammatory changes considering the possibility of an open conversion that must be done before any iatrogenic lesion occur. This policy has allowed us to avoid in our series postoperative complications such as lesions of the biliary tree. In conclusion we believe that LC for acute cholecystitis should be considered as a therapeutical option only for selected cases.

[Risk indices in geriatric surgery: ASA index versus Reiss index]. / Indici di rischio in chirurgia geriatrica: indice ASA versus Indice Reiss.

The use of the Risk Index in surgery is aimed to plan surgical strategy in order to achieve a better postoperative prognosis. This is especially true in geriatric surgery where the ASA Index and, more recently, the Reiss Index are widely employed. Since the mentioned Risk Indices are calculated on the basis of different factors, in this study we compared the two Risk Indices with the aim of verifying which index offers better prognostic indications. 210 patients, aged over 70 years, undergoing surgical treatment, were investigated. The patients were grouped according to the ASA and Reiss Indices. The ASA Index showed good correlation only with postoperative mortality. The three classes of Reiss Index showed a significant correlation with the incidence of post-operative morbidity and mortality (p.o. morbidity: 7.1%, 21.5%, 30.3%; p.o. mortality; 1.7%, 9.2%, 24.2% -Chi 2 = 20.7; p < 0.001). Our results support the hypothesis that Reiss index offers better prognostic evaluation of postoperative outcome, suggesting its use in assessing postoperative prognosis in geriatric patients. In addition, our observation confirms the criticism reported of the ASA Index, merely considered as an indicator of health status regardless of surgical treatment. In conclusion, routine preoperative evaluation of the Reiss Index should be advised in geriatric patients with the aim to forecasting surgical risk in the first place, and them modifying operative strategy in order to improve postoperative results.

[Cholelithiasis in the patient with cirrhosis of the liver: surgical aspects]. / La calcolosi della colecisti nel paziente con cirrosi epatica: aspetti di interesse chirurgico.

Open cholecystectomy in cyrrotic patients with good liver functions has operative mortality similar to normal subject (0.5-1%), while in patients with severe hepatic cyrrosis mortality varies between 7 and 83%. In this study we have evaluated the post operative results in cyrrotic patients undergone to open cholecistectomy in order to evaluate indications, controindications and risk factors related to surgery. In the last 7 years 34 patients with liver cyrrosis have been operated for biliary calculi, one of them had laparoscopic cholecystectomy. Morbidity was 29.4% (10 cases) mortality 8.8% (3 cases). Jaundice was the main indication for emergency (66.6%) in the two cases it was related to uncompensated liver functions. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) can demonstrate today the causes of jaundice avoiding unecessary operations. Post operative evaluations of our series confirm that operative risk is strictly related to epatic disease and to an appropriate surgical option. Moreover patients with compensated liver cyrrosis, (Child A), do not represent anymore a controindication to laparoscopic cholecystectomy that has less septic post operative complications when compared to open surgery.